1. Field of the Invention
The present invention relates to the field of medical triage for health care plans, and more particularly, to a method and system for automated medical triage in a workers compensation plan.
2. Description of the Related Art
As is known in the art, medical triage is the act of categorizing or classifying patients (e.g., ill or injured persons) according to the severity of their health conditions and thereby determining who need services first. With rising health care and workers compensation costs, medical triage was designed to maximize and create the most efficient use of scarce managed care resources in medical personnel, medical facilities, and the like. While medical triage commonly occurs in emergency rooms, it can occur in other health care settings such as managed care organizations, workers compensation insurance, health care plans, and health care provider systems to steer patients away from more costly care and provide more appropriate services. For instance, medical triage can be used to steer a child with a cold away from an emergency room to preserve the latter for actual medical emergencies. Indeed, these health care organizations and systems have set up “triage centers” to serve as an extension of the utilization review process, as diversions from emergency room care, or as case management resources.
In the current medical triage environment for a managed care program, such as workers compensation (WC), a work injury claim is first called in from an employer of the injured worker (IW) to a telephone reporting center of a workers compensation insurance carrier or health care plan provider. The health and/or workers compensation insurance or care provider may have one or more telephone reporting centers handling the initial claim reportings. The telephone reporting center then performs logistic data collection and entry of information relating to the claim, such as the name of the injured person/worker, social security number of the worker, the employer's address and plant location of the accident and description of the accident. The collected claim information relating to the injured worker and the accident is then transferred out of the telephone reporting center to a local claim service center, (also known as an adjusting field office or AFO) via a claim management system (e.g., T-MATE of Travelers), wherein the AFO is a triage center of the health and/or workers compensation insurance or health plan provider. As with the telephone reporting center, there may be more than one local claim service center.
At the local claim service center, a case or claim handler is assigned to the claim. Part of the normal case set up of the case handler is to review the basic facts from the collected claim information and contact the injured worker to obtain additional facts and the injured worker's description of the accident. The case handler also contacts the employer to verify the information originally obtained by the telephone reporting center from the employer. Additionally, if a physician had provided medical care to the injured worker, the case handler also seeks out the physician to obtain the physician's diagnosis or prognosis of the injured worker and his/her injury. After completing the aforementioned inquiries, the case handler documents the additional facts along with the originally collected claim information, and sends via a system interface, to a medical case manager (MCM). The MCM's task is to review the set of facts and—based on his/her professional opinion as an MCM—determine whether the return-to-work (RTW) time for the injured worker can be impacted. For instance, if the injured worker is to be out for 30 days, can he/she return to work earlier (e.g., in 20 days) if additional medical attention is given; or if the RTW time is 19 days, can he/she come back in 14 days. There are certain instances where the RTW time cannot be impacted, such as when the injured worker was already back at work after the accident and when the worker suffered a fatal injury in the accident. If the MCM judges that the RTW time will not be impacted, the MCM will document a non-referral into the nurse's integrated case management system (ICMS). However, if the MCM judges that the RTW time can be impacted, the MCM will open a medical referral and assignment for the injured worker in ICMS. The assigned nurse will then co-manage the claim with the claims adjuster (i.e., MCM), and work with the appropriate physicians to provide the necessary medical attention and treatment plan to expedite the recuperation of the injured worker and shorten the RTW time. This is because for workers compensation, it is the workers compensation carrier, or self-insured employer, that pays for the medical treatment of the injured worker along with the indemnity payment (i.e., wage replacement) to the injured worker while he/she is not able to work. Thus, it is in the interest of the workers compensation carrier to accelerate and pay a little more on the medical treatment and impact the RTW time of the injured worker in order to cut down on the higher cost of indemnity payment.